[NPINumber] [Date] «PROVIDERNAME» «PROVIDERADDRESS» «PROVIDERCITYSTATEZIP» ATTENTION: COMPLIANCE. Subject: Additional Documentation Request (ADR)

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1 [Date] [NPINumber] «PROVIDERNAME» «PROVIDERADDRESS» «PROVIDERCITYSTATEZIP» ATTENTION: COMPLIANCE Subject: Additional Documentation Request (ADR) Dear Medicare Provider: The Centers for Medicare & Medicaid Services (CMS) has retained StrategicHealthSolutions, LLC (Strategic) as the Supplemental Medical Review Contractor (SMRC) to conduct medical record review of selected Part A and Part B claims. Additional information regarding this contract can be found at: This notice serves to request documentation for the post-payment medical review of Medicare claim(s) listed in the enclosure. Strategic does not reimburse the cost associated with copying of medical records from any setting. When records are requested, the expense of supplying medical records is a part of the administrative costs of doing business with Medicare. Therefore, invoices from record retention centers and copying agencies are not eligible for reimbursement. In accordance with Social Security Act Sections 1156 [42 U.S.C. 1320c-5], 1833 [42U.S.C ] (e), and 1815 [42 U.S.C. 1395g] (a), as a Medicare provider, you must provide documentation and medical records upon request to support claims for Medicare services. This request complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, which allows release of information without explicit patient consent for treatment, payment, and healthcare operations. According to Medicare guidelines, the Medicare Part B program covers medical and other health services such as office visits, drugs and biologicals, and laboratory and other diagnostic tests furnished by physicians and other clinicians. The Office of Inspector General (OIG) issued a report entitled, Review of Clinicians Associated with High Cumulative Payments Could Improve Medicare Program Integrity Efforts, A The OIG found that Medicare paid more than $65 billion for Part B services each calendar year from 2008 through In each of the four years, approximately 2 percent of clinicians were responsible for almost 25 percent of all Part B payments with annual payments of more than $500,000 per clinician. These clinicians were responsible for average annual payments of approximately $1 million. The OIG report

2 stated clinicians included physicians, nurse practitioners, and physician s assistants and noted that these clinicians may not have been the billing provider. CMS completed data analysis to identify clinicians who furnished services responsible for high cumulative payments during the 2012 calendar year and directed Strategic to review a sample of claims for services furnished by these clinicians. This constitutes new and material evidence that establishes good cause for reopening as required under 42 CFR (b). Strategic is requesting additional documentation for these claims for Supplemental Medical Review of Part B services authorized by CMS. Please submit the following supporting information, as applicable, for each claim requested: Copy of the claim bill Physician orders Physician progress notes History and Physical Procedure reports Diagnostic radiology reports Laboratory reports Pathology reports Radiation therapy treatment plan, treatment records, and related documentation Nursing documentation Medication administration records Infusion records, including documentation to support timed codes billed Copies of patient notices given (for example, Advance Beneficiary Notice of Noncoverage) Signatures/credentials of professionals providing services, including signature log or attestation for medical record entries that are not signed or do not contain legible signatures. Electronic record protocol/policy for electronic signatures All other medical record documentation to support the service(s) billed Note: Medicare requires that medical record entries for services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamp signatures are not acceptable. Beneficiary identification, date of service, and provider of the service(s) should be clearly identified on the submitted documentation. Documentation submitted in response to this request shall comply with these requirements. This may require providers to contact the hospital or other facility

3 where services were provided to obtain signed progress notes, plan of care, discharge summary, etc. If signature requirements are not met, the reviewer will conduct the medical review without considering the documentation with the missing or illegible signature. This could lead the reviewer to determine that medical necessity for the service(s) billed has not been substantiated. Strategic recommends providers review their documentation prior to submission, to ensure that all medical record entries and orders are signed appropriately. For documentation with a missing or illegible signature, a signature log or signature attestation may be submitted in addition, as part of the ADR response. For detailed guidance regarding Medicare signature requirements, refer to the Medicare Program Integrity Manual, Publication , Chapter 3 and Section A copy of this request letter should be affixed to the documentation submitted. All documentation should be received at Strategic within 45 days of the date of this notice. Please refer to the enclosed Instructions for Submitting Requested Documentation/Medical Records for additional information on document preparation and available submission methods. A response is required even if you are unable to locate the requested documentation. Failure to comply with this request could result in potential denial and recoupment of payment previously issued. You will receive a review results letter after a determination has been made. The results letter will stipulate if any overpayment(s) were identified. Questions regarding this request should be directed to the SMRC Customer Service at Sincerely, The Supplemental Medical Review Contractor Enclosures

4 Point of Contact Information It may be necessary for Strategic to contact your organization regarding the claims provided to Strategic. Please provide a primary and secondary Point of Contact (POC) for your organization in the space provided below. POC Name Telephone Facsimile Primary Not Applicable (N/A) N/A N/A Secondary N/A N/A N/A ADR Claim Sample List Please refer to the enclosed Instructions for Requested Documentation/Medical Records for additional information on document preparation and available submission methods. Attach a copy of this ADR Claim Sample List to the front of each record. Clearly identify the corresponding sampled claim from the list by circling or marking an (x) next to the Sample ID and beneficiary name. The following claims have been selected for post-payment review. Please send the requested documentation listed on the ADR for each claim. Case Sample ID Beneficiary Name Date of Birth Claim Number Claim From Date Claim To Date N/A N/A N/A N/A N/A N/A

5 Instructions for Submitting Requested Documentation/Medical Records How to prepare requested documents for efficiency during the record intake and medical review process: 1. Prepare documents/records in the order of the requested information listed on the enclosed ADR letter. 2. Do not staple any pages together in the record. Paper clips and rubber bands are acceptable to keep the records organized, if necessary. 3. Ensure all submitted pages are complete, legible, and include both sides of the page and edges where applicable. 4. Bundle records for each claim sample separately. Each record should be its own file regardless of the size and/or submission method including faxes. 5. Attach a copy of the ADR Claim Sample List to the front of each record. Clearly identify the corresponding sampled claim from the list by circling or marking an (x) next to the Sample ID and beneficiary name. Please choose ONE of the following methods of submission after following steps 1-5: esmd Providers now have the option to submit requested documentation via the Electronic Submission of Medical Documentation (esmd) mechanism. For more information about esmd, see Faxing Fax documents for each claim separately to enable us to ensure receipt of all requested documentation for each claim. Please include a cover sheet stating the number of pages faxed. Fax information to: Mail Paper copies or CD/DVDs may be mailed by any means including US Postal Service, FedEx, UPS, or certified mail to the following address: StrategicHealthSolutions, LLC ATTN: Supplemental Medical Review Contract Project ID: Y2P34 *Imaged records can be submitted via an encrypted CD. Do NOT submit the password information with the CD. Provide the password in a separate mailing or call customer service. Each medical record should be saved as a separate file and identified by the Sample ID provided on the ADR Claim Sample List. Files must be in.pdf format and sent in a tamper-proof package. Please label CD with NPI # and Project ID. Direct questions and/or faxing issues to Customer Service at